Impound Release Insurance Verification Form
Use this form to verify vehicle insurance and provide the details needed for impound release.
Vehicle and Impound Record
Vehicle Owner/Claimant Name
*
First Name
Middle Name
Last Name
Vehicle Make
*
Vehicle Model
*
Vehicle Year
*
Vehicle Color
License Plate or Plate Identifier
*
Impound Lot Name / Location
*
Impound Case / Reference Number
*
Date and Time of Impound
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Insurance Verification
Insurance Carrier Name
*
Policy Reference Number
Policy Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Policy Expiration Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Proof of Insurance
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Policy Active and Covers Vehicle for Release
*
Yes
No
Release Authorization and Contact
Relationship to Vehicle Owner
*
Please Select
Owner
Spouse/Partner
Family Member
Employee
Authorized Agent
Attorney
Other
Best Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Authorization and Acknowledgment
*
Submit
Submit
Should be Empty: